Mental Health Questionnaire

1. This past week, I consistently achieved the quality of sleep necessary to wake up feeling rested and clear-headed.

2. This past week, I prioritized fueling my body with high-quality nutrition and staying properly hydrated.

3. This past week, I made time for intentional movement to maintain my physical ability on a daily basis.

4. This past week, I took steps to ensure my external environment supported a state of internal calm rather than chaos.

5. This past week, I stayed on top of my life administration (bills, appointments, and other admin obligations) without significant stress.

6. This past week, I dedicated sufficient time to self-care (maintenance and care of my physical, emotional and spiritual wellbeing).

7. This past week, I actively engaged with my community and felt a genuine sense of social connection and belonging.

8. This past week, I sought out or embraced opportunities to be of use and service to others.

9. This past week, I made decisions that were clearly organized by my core values and long-term life goals.

10. This past week, I experienced moments of genuine joy, play, or awe that helped refill my internal tank.

WSA Score (0-10 Heal Stage); (11-20 Grow Stage); (21-30 Thrive Stage)

Wellbeing Assessment Total Calc

The following questions are optional.

If there is a specific stressful experience that you would like to track, then please answer the following questions, otherwise please click "submit" at the bottom of the page.

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Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience.

Keeping your worst event in mind, please read each problem carefully and then select one of the numbers to the right to indicate how much you have been bothered by that problem in the past month.

Description of the specific, worst stressful experience you are holding in mind. Keep in mind that when you come back to these questions in the future, we will ask you to answer with respect to this same event:

1. Repeated, disturbing, and unwanted memories of the stressful experience?

2. Repeated, disturbing dreams of the stressful experience?

3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?

4. Feeling very upset when something reminded you of the stressful experience?

5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?

6. Avoiding memories, thoughts, or feelings related to the stressful experience?

7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?

8. Trouble remembering important parts of the stressful experience?

9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?

10. Blaming yourself or someone else for the stressful experience or what happened after it?

11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?

12. Loss of interest in activities that you used to enjoy?

13. Feeling distant or cut off from other people?

14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?

15. Irritable behavior, angry outbursts, or acting aggressively?

16. Taking too many risks or doing things that could cause you harm?

17. Being “superalert” or watchful or on guard?

18. Feeling jumpy or easily startled?

19. Having difficulty concentrating?

20. Trouble falling or staying asleep?

PCL-5 Total Score (cutoff score between 31-33 is indicative of probable PTSD)

Evidence for the PCL for DSM-IV suggests that a 5-10 point change represents reliable change (i.e., change not due to chance) and a 10-20 point change represents clinically significant change. Therefore, it was recommended to use 5 points as a minimum threshold for determining whether an individual has responded to treatment and 10 points as a minimum threshold for determining whether the improvement is clinically meaningful using the PCL for DSM-IV.

PCL-5 Category

In the past month, how much were you bothered by:

Rows	Not at all	A little bit	Moderately	Quite a bit	Extremely
1. Repeated, disturbing, and unwanted memories of the stressful experience?
2. Repeated, disturbing dreams of the stressful experience?
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
4. Feeling very upset when something reminded you of the stressful experience?
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
6. Avoiding memories, thoughts, or feelings related to the stressful experience?
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
8. Trouble remembering important parts of the stressful experience?
9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
10. Blaming yourself or someone else for the stressful experience or what happened after it?
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
12. Loss of interest in activities that you used to enjoy?
13. Feeling distant or cut off from other people?
14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
15. Irritable behavior, angry outbursts, or acting aggressively?
16. Taking too many risks or doing things that could cause you harm?
17. Being “superalert” or watchful or on guard?
18. Feeling jumpy or easily startled?
19. Having difficulty concentrating?
20. Trouble falling or staying asleep?

OLD PHQ-9 Score (0-4 Minimal) (5-9 Mild) (10-14 Moderate) (15-19 Moderately-Severe) (20+ Severe)

This easy to use patient questionnaire is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders.[1] The PHQ-9 is the depression module, which scores each of the nine DSM-IV criteria as "0" (not at all) to "3" (nearly every day). It has been validated for use in primary care.[2] It is not a screening tool for depression but it is used to monitor the severity of depression and response to treatment. However, it can be used to make a tentative diagnosis of depression in at-risk populations - eg, those with coronary heart disease or after stroke.[3, 4] When screening for depression the Patient Health Questionnaire (PHQ-2) can be used first (it has a 97% sensitivity and a 67% specificity).[5]If this is positive, the PHQ-9 can then be used, which has 61% sensitivity and 94% specificity in adults.

OLD GAD-7 Score (0-5 Minimal) (6-10 Mild) (11-15 Moderate) (16-21 Severe)

The GAD-7 originates from Spitzer RL, Kroenke K, Williams JB, et al; A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006 May 22;166(10):1092-7. GAD-7 © Pfizer Inc. all rights reserved; used with permission. The GAD-7 score is calculated by assigning scores of 0, 1, 2, and 3, to the response categories of 'not at all', 'several days', 'more than half the days', and 'nearly every day', respectively, and adding together the scores for the seven questions. Scores of 5, 10, and 15 are taken as the cut-off points for mild, moderate and severe anxiety, respectively. When used as a screening tool, further evaluation is recommended when the score is 10 or greater. Using the threshold score of 10, the GAD-7 has a sensitivity of 89% and a specificity of 82% for GAD. It is moderately good at screening three other common anxiety disorders - panic disorder (sensitivity 74%, specificity 81%), social anxiety disorder (sensitivity 72%, specificity 80%) and post-traumatic stress disorder (sensitivity 66%, specificity 81%).[3]

OLD PCL-5 Total Score (cutoff score between 31-33 is indicative of probable PTSD)

Evidence for the PCL for DSM-IV suggests that a 5-10 point change represents reliable change (i.e., change not due to chance) and a 10-20 point change represents clinically significant change. Therefore, it was recommended to use 5 points as a minimum threshold for determining whether an individual has responded to treatment and 10 points as a minimum threshold for determining whether the improvement is clinically meaningful using the PCL for DSM-IV.

Rows	Not at all	Several Days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so figety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself

Rows	Not at all	Several Days	More than half the days	Nearly every day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen